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Difference of opinion from doctors

I injured my back at work 11/23/2011 lifting a box that was loaded improperly and with more than allowable weights. I did months of chiropractic, physical therapy and massage therapy before having this MRI done. I had 2 spinal injections at the l2 but made pain horribly worse, with no relief at all over the last 2 1/2 months. I have had horrible back pain with stabbing pain from my spine down both buttocks when I walk, stabbing pain in my butt bone when i change positions or sit or lay at an angle, stabbing pain down my left leg and down the right just past my butt. I get cramping pain in the front of my legs to my feet. The other doctor refereed me to a surgeon that believes its a problem at the L5 and he wants to do a discectomy there. My major concern is why with the same symptoms same mri one gave me shots at the L2 herniation and the new doctor wants to do surgery at the L5?

Clinical Data: Low back pain radiating into left leg. Radiculopathy. Lifting injury.

Technique: Multiplanar exam obtained using a variety of pulse sequences. Contrast: none

Comparison: None

Findings: Paravertebral space: unremarkable

Conus: Normal in signal position and morphology terminating at the T12-L1 level.

Bones: Moderate lumbar spondylosis is present most prominent at the L1-L2. Exaggerated lumbar lardosis noted.

Levels: L1-2: Disc signal is diffusely decreased. Left posterior disc protrusion impresses upon the left Ventral thecal sac. Asymmetry and traversing L2 roots with left posteriorly positioned relative to the right. Central canal is approximately 10.5 mm in ap dimension, low normal. Ther is no foraminal stenosis. Mild ligamentum flavum hypertophy noted bilaterally.

L2-3: disc height and signal are preserved. No spinal stenosis or foraminal stenosis noted.

L3-4: disc signal and height are preserved on T2 imaging. Increased signal in the anterior annulus near junction with antero-superior L4 vertebra is consistent with annular sprain. No spinal stenosis or foraminal stenosis noted.

L4-5: disc signal and height are mildly decreased. Posterior disc buldge flattens the ventral thecal sac, abutting the travering left L5 root. Mild ligamentus flavum hypertrophy is present. No central stenosis noted. The foraminal narrowing is left more the right but minimal without nerve encroachment.

L5-S1: Disc signal is diffusely decreased. Shallow posterior disc protrusion is broad based mildly encroaching upon bilateral S1 roots, right more than left. No foraminal stenosis.

Other findings: loss of disc height and signal noted on T12-L1 there is in addition left posterior extrusion at this level impresses on left ventral thecal sac. Central canal is 9.7 mm in ap dimension, mildly decreased.

Impression:

1. Mild-to-moderate lumbar and lower thoracic disc disease and spondylosis.

2. Left posterior disc extrusion at T12-L1 is associated with mild central stenosis.Left posterior disc protrusion at L1-2 is associated with asymmetry and traversing L2 roots withe left L2 root posteriorly positioned relative to the right. Posterior broad based L5-S1 protrusion is associated with encroachment on traversing S1 roots, right more than left.

3. Recommend clinical correlation.

4. mild lumbar facet osteoarthritis.
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replied July 10th, 2012
Especially eHealthy
rlwalker75,

A lot of it has to do with the third recommendation:

"3. Recommend clinical correlation."


With the injections, the physician was probably trying to calm down the problems around the DDD at the upper lumbar level. The protrusion at this level does not press on the nerve root. While the surgeon can't do much for the DDD (except a fusion), but you do have a posterior broad based L5-S1 protrusion, which is associated with encroachment on traversing S1 roots. This may be irritating the nerve roots. Thus, the microdiscectomy.

However, if the S1 nerve root was being significantly bothered, you would probably note numbness/tingling on the lateral side of the foot and posterior aspect of the leg. The problem in the front of the leg is usually L5 or L4.

Without knowing what the surgeon found on physical examination, it is hard to pick his brain.


But, as the third recommendation states, you can't just go on a study. You have to correlate the findings on the study with the patient's history, symptoms, and physical examination. If the study findings and the patient findings correlate, then surgical intervention is usually very successful. If the findings do not correlate, then surgery should usually not be performed.


You should ask your surgeon the same questions you posed here. He is in the best position to answer them.

Good luck.
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replied July 12th, 2012
Thank you very much, that was very helpful.
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